Overview

This video provides a comprehensive walkthrough of documenting a Nursing Visit Note (NVN) within the HospiceWorks platform. It guides clinicians through the entire lifecycle of a visit—from selecting a patient to using advanced AI tools for clinical accuracy and narrative generation.


Video Highlights


1. Initiating the Visit Note

The video demonstrates two primary ways to start documentation:

  • From the Dashboard: Clicking a hyperlinked date under "Next Visit" for patients already on your daily schedule.
  • Manual Search: Navigating to the "Patients" tab to locate a patient not currently on your schedule, then selecting Care Management > Create New Documentation > Nursing Visit Note.
  • Linking Visits: The narrator shows how to "Link to Visit" if a note is started independently of the calendar to ensure proper scheduling alignment.

2. The Documentation Workflow

HospiceWorks uses an accordion-style layout for streamlined data entry. Key sections covered include:

  • Visit Information & Vitals: Capturing time-in/time-out, mileage, and essential vitals.
  • Pain Assessment: Utilizing interactive scales and frequency selectors.
  • Smart Assessments: A "Logic-based" approach where selecting new or worsening symptoms (e.g., Agitation) automatically triggers the required sub-panels (e.g., Mental Neurological) for further detail.
  • Medication Management: A deep dive into documenting PRN medications, including administration logic, effectiveness, and reasons for non-administration, all of which flow directly into the MAR.

3. Care Plans and Education

  • Patient/Family Education: Documenting emotional support, caregiver involvement, and confirmation of understanding.
  • Goal Tracking: Reviewing and updating goals and interventions across multiple active care plans (e.g., Skin Integrity, Comfort Measures).
  • Future Planning: Using the "Next Visit" panel to set clinical focus areas and view the next scheduled date.

4. Advanced AI QA & Narrative Summary

The finale of the video highlights the AI QA Review tool, which acts as a virtual clinical supervisor:

  • Clinical Analysis: Compares current visit data against patient baselines to flag anomalies like high blood pressure or fever.
  • Compliance Scoring: Provides a 1–10 score and lists "Critical" or "High" priority items that need correction before the note is signed.
  • Narrative Generation: Demonstrates how the AI pulls structured data (vitals, functional status, and interventions) to draft a professional, cohesive Documentation Summary that supports hospice eligibility.

Key Takeaway

The video emphasizes that while the software automates much of the "heavy lifting" through red-flagging required fields and generating AI summaries, the clinician remains the final editor, ensuring all documentation accurately reflects the patient's status and care provided.